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Asymmetric Posterior Thoracolumbar Fixation Following a Posterolateral Transpedicular Approach for Unilateral Vertebral Disease

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Asymmetric Posterior Thoracolumbar Fixation Following a Posterolateral Transpedicular Approach for Unilateral Vertebral Disease ORIGINAL ARTICLE doi: 10.2176/nmc.oa.2014-0085 Neurol Med Chir (Tokyo) 55, 564–569, 2015 Online March 23, 2015 Asymmetric Posterior Thoracolumbar Fixation following a Posterolateral Transpedicular Approach for Unilateral Vertebral Disease Murat YILMAZ,1 Ahmet KARAKASLI,2 Orhan KALEMCI,1 Ceren KIZMAZOGLU,1 Zafer K. YUKSEL,3 Nuri M. ARDA,1 and Kemal YUCESOY1 Departments of 1Neurosurgery and 2Orthopedics, Dokuz Eylül University, Izmir, Turkey; 3Department of Neurosurgery, Sütçü imam University, Izmir, Turkey Abstract The present study aimed to evaluate the clinical outcomes of patients who underwent asymmetrical pos- terior screw fixation for the treatment of unilateral posterior vertebral pathological entities. The study included 21 patients with a spinal tumor who underwent asymmetrical posterior spinal fusion surgery between April 2009 and March 2012. The American Spinal Injury Association (ASIA) motor score visual analog scale (VAS) score were used as the outcome measure at admission and follow-up. Among the 21 patients, 12 were male and 9 were female, and mean age was 50.71 (range, 24–78) years. Mean follow-up was 16.04 (range, 4–47) months. Postoperatively, neurological findings did not deteriorate in any of the patients. Among the ASIA grade C and D patients, eight (38%) of them exhibited clinical stability or recovery to ASIA E, whereas none of the ASIA B patients scores changed postoperatively. Perioperative complications were noted in six patients (28%). Spinal stability and fusion were achieved in 18 (85%) patients. The surgical asymmetrical fixation technique described reduced the duration of surgery, and the patients required less dissection of paraspinal muscles than bilateral symmetrical fixation. Asymmetri- cal fixation provides good stabilization for unilateral thoracolumbar vertebral pathological entities, and facilitates rapid rehabilitation of such patients, who are often elderly with comorbidities. Key words: asymmetric fixation, thoracolumbar, unilateral vertebral disease, transpedicle Introduction (PTA) is favored in cases requiring multilevel or circumferential (both anterior and posterior) Pedicle screw instrumentation is widely used for decompression and fusion. This approach facili- the stabilization of single and multiple level spinal tates direct decompression, reconstruction of the fusions. Although the ideal fixation construct stiff- anterior column, height restoration, and kyphosis ness is unknown, fusion rates have improved as correction.1,4,5) the rigidity of systems have increased.1–3) Surgeons In 1992, Kabins et al. reported that clinical advocate enhancing stabilization across vertebral results with unilateral variable screw placement lesions by extending instrumentation to include instrumentation were nearly identical with those of additional levels and sides. Extending instrumenta- bilateral instrumentation.6) However, they confined tion, however, has some disadvantages, including unilateral instrumentation to single-level (L4–L5) increased cost, larger surgical exposure, more bone fusion, recommending that unilateral instrumenta- destruction, and a higher rate of screw-related tion not be used for multilevel fusion and that the complications at each level. Posterior fixation has results with unilateral variable screw placement also been shown to be responsible for a reduction instrumentation not be extrapolated to other less in bone mineral content due to stress shielding.3) rigid designs of pedicle screw fixation. Single-stage posterolateral transpedicular approach The present study aimed to evaluate the clinical outcomes in patients who underwent asymmetrical posterior screw fixation for unilateral posterior Received March 13, 2014; Accepted September 8, 2014 vertebral pathological entities. 564 Asymmetric Posterior Thoracolumbar Fixation 565 Materials and Methods achieved, accompanied by posterior asymmetrical vertebral fixation under fluoroscopic guidance I. Study design (Fig. 1). In four patients, the pedicles with tumor This retrospective study included 21 patients who involvement were removed to allow access to the underwent surgery for spinal tumors with asym- vertebral body; the nerve roots were preserved in all metrical posterior spine fusion at our university cases. Next, the nerve roots were gently retracted, between April 2008 and March 2012. All patients a titanium mesh cage was placed over the verte- underwent complete preoperative diagnostic work- brectomy defect under fluoroscopic guidance, and up, including X-ray, computed tomography (CT), then posterior rods were locked (Fig. 2). In other and magnetic resonance imaging (MRI). Indications patients, we performed tumor resection and asym- for surgical interventions were spinal tumors with metric posterior lumbar fixation (Figs. 3, 4). The asymmetrical posterior spine fusion and unilateral patients were followed-up by the neurosurgery and posterior vertebral pathological entities. oncology departments. II. Outcome parameters Results The Tokuhashi scoring system was used to assess the patient’s prognosis and to determine Relevant clinical data for the 21 patients are shown the best therapeutic option for the patient.7–9) The American Spinal Injury Association (ASIA) motor score visual analog scale (VAS) score were used as the outcome measure at admission and follow-up (Table 1).4,10) III. Surgical technique All surgeries were performed under general anes- thesia. A single posterior midline approach was used with pedicle screw placement under fluoroscopic guidance two levels above and two levels below the spinal tumor side, and one level above and one level below on the other side. Following pedicle screw placement, decompressive laminectomy was performed, including bilateral facetectomy. Tumor A B resection and partial corpectomy was performed after removal of the intervertebral discs above and below, via PTA, using an osteotome, curette, and rongeur. In the patient with hemangioma, open vertebroplasty with polymethylmethacrylate was Table 1 The American Spinal Injury Association impairment scale Grade description A Complete no motor or sensory function is preserved at S4–S5. B Incomplete sensory but not motor function is preserved below the neurological level and extends through S4–S5. C Incomplete motor function is preserved below the C D neurological level and the majority of key muscles below the neurological level have a muscle grade less Fig. 1 A: Hypodense destructive lesion (white arrow) than 3. is seen in the vertebral bone on axial CT scan. B: D Incomplete motor function is preserved below the Vertebroplasty material (polymethylmethacrylate) (white neurological level and the majority of key muscles arrow) is seen on axial CT scan. C, D: Vertebroplasty below the neurological level have a muscle grade material (white arrows) (polymethylmethacrylate) and greater than or equal to 3. asymmetric posterior lumbar fixation are seen on X-rays. E Normal motor and sensory functions are normal. CT: computed tomography. Neurol Med Chir (Tokyo) 55, July, 2015 566 M. Yilmaz et al. D A B C E Fig. 2 A: Hypointense lesion is seen in L2 vertebra (white arrow) on T2-weighted sagittal MRI. B, C: Titanium cage and asymmetric posterior lumbar fixation white( arrows) are seen on X-rays. D: Hypointense lesion is seen in L2 vertebra (white arrow) on T2-weighted MRI. E: Titanium cage (white arrow) is seen on axial CT scan. CT: computed tomography, MRI: magnetic resonance imaging. A B C D E F G Fig, 3 A, B: Radiolucent lesion (osteoblastoma) is seen on the left side of L3 vertebra (white arrows) on X-rays. C, D: Hypodense destructive lesions (white arrows) are seen in the L3 vertebral bone on sagittal and axial CT scans. E, F: Asymmetric posterior lumbar fixation is seen on X-rays. G: Unilateral screw placement to the intact pedicle of L3 vertebra (white arrow) is seen on axial CT scan. CT: computed tomography. Neurol Med Chir (Tokyo) 55, July, 2015 Asymmetric Posterior Thoracolumbar Fixation 567 A B C D Fig. 4 A: Hypointense lesion is seen in vertebral bone (white arrow) on T1-weighted axial MRI. B: Unilateral screw placement to the intact pedicle of vertebral bone (white arrow) is seen on axial CT scan. Intact pedicle (white arrow) is seen on axial CT scan. C, D: Asymmetric posterior lumbar fixation is seen on X-rays. CT: computed tomography, MRI: magnetic resonance imaging. Table 2 Patients’ parameters Age Preoperative values Postoperative values Patients Sex Level Pathology (yrs) ASIA scale VAS score ASIA scale VAS score 1 43 M D 8 L3 D 3 Metastatic rectum cancer 2 55 M D 6 L3 E 3 Plasmacytoma 3 24 M E 7 L2 E 5 Hemangioma 4 53 M D 8 L3 E 3 Schwannoma 5 30 F C 9 L3 D 3 Aggressive osteoblastoma 6 78 F C 8 L2 C 3 Metastatic breast cancer 7 32 F D 8 L4 E 3 Osteoblastoma 8 58 F E 6 L2 E 2 Plasmacytoma 9 28 M B 7 L3 B 3 Metastatic colon cancer 10 50 M C 9 L3 E 3 Metastatic prostate carcinoma 11 39 M D 9 L2 E 5 Giant cell tumor 12 67 F B 7 L3 B 3 Metastatic renal cancer 13 34 F D 6 L3 D 2 Schwannoma 14 27 M D 7 L3 E 2 Osteoblastoma 15 63 F E 8 L2 E 4 Metastatic breast cancer 16 69 M D 9 L3 E 5 Metastatic prostate carcinoma 17 62 M C 6 L3 D 2 Plasmacytoma 18 52 F C 8 L2 C 6 Metastatic colon cancer 19 77 M D 7 L4 E 5 Metastatic prostate carcinoma 20 59 F E 8 L2 E 4 Metastatic renal cancer 21 65 M B 7 L3 B 3 Metastatic colon cancer ASIA: American Spinal Injury Association, F: female, M: male, VAS: visual analog scale. in the Table 2. Mean age of the 12 male and 9 had radiculopathy and 12 had myelopathy. female patients was 50.71 (range, 24–78) years. Mean Postoperative neurological findings did not dete- follow-up was 16.04 (range, 4–47) months. Eleven riorate in any of the patients. Among ASIA C and patients had metastatic tumors, four had primary D patients, eight (38%) of them exhibited clinical bone tumors, three had plasmacytomas, two had stability or recovery to ASIA E, whereas ASIA B schwannomas, and one patient had hemangioma.
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